Femoral guide and methods of precisely forming bone tunnels in cruciate ligament reconstruction of the knee

ABSTRACT

A femoral guide for precisely positioning a guide wire on a femur bone surface. A lumen allows a guide wire extending through the lumen to contact the bone surface at a location spaced a predetermined distance from an edge of the bone surface. With the guide wire driven into the bone, a bone tunnel can be formed substantially concentrically along the guide. Methods of precisely forming bone tunnels include the steps of engaging a bone surface edge with a tongue of the femoral guide, insertion of a guide wile through a femoral guide lumen, driving the guide wire into the bone through the lumen and forming a bone tunnel along the guide wire where a bone tunnel longitudinal axis is disposed from the edge engaged by die tongue a distance substantially equal to the distance that the tongue is disposed from the longitudinal axis of the lumen.

FIELD OF THE INVENTION

The present invention pertains to surgical instruments for preciselypositioning guide wires in bone allowing tunnels to be formed in thebone along the guide wires and, more particularly, to femoral guides forprecisely positioning guide wires in the femur in cruciate ligamentreconstruction of the knee allowing bone tunnels to be formed in thefemur along the guide wires at sites anatomically equivalent to thecruciate ligament and to methods of precisely forming bone tunnels.

DESCRIPTION OF THE PRIOR ART

Various surgical procedures utilize graft or prosthetic ligaments toreconstruct natural ligaments that have been damaged by injury ordisease. Where the ligaments to be reconstructed are found in joints orarticulations of the body, i.e., the connections of the various surfacesof the bones in the body, graft or prosthetic ligaments are typicallyimplanted and fixated in bones of the joint at sites anatomicallyequivalent to the natural ligament. In cruciate ligament reconstruction,such as anterior cruciate ligament reconstruction of the knee, tandem,isometrically positioned bone tunnels are formed, respectively, in thetibia and femur at sites anatomically equivalent to attachment of theanterior cruciate ligament, and a graft or prosthetic ligament havingbone blocks at its ends is inserted in the bone tunnels to extend acrossthe knee joint with the bone blocks disposed, respectively, in the bonetunnels. Interference bone fixation screws are inserted in the tibialand femoral bone tunnels to be positioned laterally between the boneblocks and walls of the bone tunnels to fixate the ligament and providea bone-tendon-bone graft. In anterior cruciate ligament reconstructionof the knee, it is very important that the bone tunnels be located atthe anatomic sites of attachment of the anterior cruciate ligament; and,where anterior cruciate ligament reconstruction is performed as an opensurgical procedure utilizing relatively long incisions on the order often inches in length to access the knee joint, the increased room formaneuverability afforded by the long incisions can enhance properplacement of the tibial and femoral bone tunnels. However, open surgerypossesses numerous disadvantages over closed, or least invasive surgery,including increased invasiveness and trauma, prolonged hospitalizationand rehabilitation times, increased patient discomfort, possibleviolation of capsular mechanoreceptors, dessication of articularcartilage and delayed post-surgical mobility. Accordingly, it ispreferred to perform anterior cruciate ligament reconstruction as aleast invasive, closed, or endoscopic, procedure wherein portals ofminimal size, such as are formed with a puncture or stab wound, intissue adjacent the knee are utilized to access the knee joint with theknee being visualized with an arthroscope, the portals being just largeenough to accommodate surgical instruments inserted at the knee joint.Arthroscopic anterior cruciate ligament reconstruction provides numerousbenefits over open surgery including minimal invasiveness and trauma,performance on an outpatient basis, reduced rehabilitation time,decreased patient discomfort, early, aggressive range of motion,cosmetically pleasing incisions, completion with tourniquet times underone hour, the opportunity to perform a diagnostic arthroscopy withouthaving to commit to anterior cruciate ligament reconstruction unlessconfirmed by the diagnostic findings and early weight bearing withoutloss of fixation.

Where cruciate ligament reconstruction is performed as a closed, orendoscopic, surgical procedure, the small size of the portals limitsaccess to and maneuverability at the knee joint making it relativelymore difficult to precisely place the tibial and femoral bone tunnels atsites anatomically equivalent to the cruciate ligaments. In most cases,guide wires or pins are inserted through arthroscopic size portals fromexternally of the body and are driven, from externally of the body, inthe tibia and femur at desired locations for longitudinal axes, orcenters, of the tibial and femoral bone tunnels, allowing the bonetunnels to be formed along the guide wires, such as by drilling orreaming, substantially coaxially or concentrically with the guide wires.Although the guide wires are effective in guiding instruments, such asdrills and reamers, utilized to form the bone tunnels, problems canarise in arthroscopic cruciate ligament reconstruction in preciselypositioning or locating so the guide wires. If the guide wires are notlocated and inserted at sites anatomically equivalent to attachment ofthe cruciate ligament, the tibial and femoral bone tunnels, as guided bythe guide wires, will not be properly located, and ligamentreconstruction will be impaired. In arthroscopic anterior cruciateligament reconstruction, it is difficult to position a guide wire on thefemur at a position corresponding to the anatomic center of attachmentof the anterior cruciate ligaments. In order to position a tip of theguide wire on the femoral condyle at the anatomic center for theanterior cruciate ligament and drive the guide wire into the femur suchthat a bone tunnel formed along the guide wire will have a longitudinalaxis substantially aligned with the anatomic center of the anteriorcruciate ligament, the guide wire must be inserted through a tibial bonetunnel from a portal of minimal size, and a tip of the guide wire mustbe located on the femoral condyle with the guide wire held and driveninto the femur from externally of the knee. When positioning the tip ofthe guide wire on the femoral condyle, it is desired that the tip bepositioned high in a notch on the femoral condyle, the notch beingformed in a notchplasty procedure prior to formation of the bonetunnels, such that the longitudinal axis of the femoral bone tunnel willbe disposed sufficiently anterior, i.e., approximately 6–7 millimeters,to the posterior edge or “over-the-top ridge” of the notch and thefemoral bone tunnel will be as far posterior as possible while stillallowing a tunnel and not a trough with the cortical margin of the femurbeing neither too wide nor too narrow. However, it is extremelydifficult in arthroscopic anterior cruciate ligament reconstruction toposition and hold the guide wire from externally of the knee such thatthe tip of the guide wire is optimally, isometrically positioned on thefemur; and, even when properly positioned, the guide, wire can slip orshift prior to being driven into the femur resulting in an improperlypositioned femoral bone tunnel and impaired placement of the graft orprosthetic ligament. Where instruments are used to help guide or holdthe guide wire, the instruments themselves can slip or shift causingdisplacement of the guide wire; and, frequently, the use of instrumentsdoes not eliminate the need for a surgeon to estimate where to placeinstruments such as drills or reamers when forming the femoral bonetunnel along the guide wire. Accordingly, arthroscopic anterior cruciateligament reconstruction as presently performed lacks instruments forprecisely positioning a guide wire on the femur at a site anatomicallyequivalent to the anterior cruciate ligament to allow a femoral bonetunnel formed substantially coaxially or concentrically along the guidewire to be optimally, isometrically positioned.

SUMMARY OF THE INVENTION

Accordingly, it is a primary object of the present invention to overcomethe above-mentioned disadvantages of femoral guides and methods offorming bone tunnels.

Another object of the present invention is to provide a guide forprecisely positioning a guide wire on a bone surface in relation to areference edge on the bone surface engaged by the guide.

A further object of the present invention is to provide a femoral guidefor precisely positioning a guide wire in the femur such that a bonetunnel formed along the guide wire has a longitudinal axis substantiallyaligned with the anatomic center of attachment of the cruciate ligament.

It is also an object of the present invention to provide a guide havinga tongue for engaging an edge on a bone surface to position a guide wireinserted through the guide on the bone surface such that a longitudinalaxis of a tunnel formed substantially concentrically along the guidewire is a predetermined distance from the edge.

Yet another object of the present invention is to provide a femoralguide having a tongue and a lumen having a longitudinal axis disposed apredetermined distance from the tongue such that a guide wire insertedin the lumen has a longitudinal axis disposed substantially thepredetermined distance from die tongue.

A still further object of the present invention is to provide a femoralguide for precisely positioning a guide wire on the femur such that abone tunnel formed along the guide wire has a longitudinal axisapproximately 6–7 millimeters anterior to a posterior edge or“over-the-top ridge” of a notch on the femoral condyle.

An additional object of the present invention is to provide a guidehaving a stylus for being driven into the bone to stabilize the guidedun insertion of a guide wire into the bone along the guide.

Furthermore, it is an object of the present invention to provide amethod of precisely forming bone tunnels in a joint of the bodyendoscopically with a guide inserted at the joint from a portal ofminimal size to position a guide wire on a surface of a bone of thejoint such that the guide wire is a predetermined distance from areference edge on the bone surface engaged by the guide allowing theguide wire to be driven into the bone for forming a bone tunnel alongthe guide wire.

Another object of the present invention is to provide a method offorming bone tunnels in a bone of a joint of the body endoscopicallywith a guide inserted at the joint from a portal of minimal size andincluding positioning a tongue of the guide against an edge of a bonesurface of the bone such that a guide wire inserted through a lumen ofthe guide is positioned on the bone surface a distance from the edgethat is substantially equal to the distance from the tongue to alongitudinal axis of the lumen.

It is also an object of the present invention to provide a method offorming a femoral bone tunnel in arthroscopic cruciate ligamentreconstruction of the knee including the steps of inserting a femoralguide through a tibial bone tunnel from an arthroscopic size portal,positioning a tongue of the femoral guide against a posterior edge of asurface of the femoral condyle, inserting a guide wire through a lumenof the femoral guide to contact the surface of the femoral condyle anddriving the guide wire into the femur such that a bone tunnel formedsubstantially concentrically or coaxially along the guide wire has alongitudinal axis spaced from the reference edge a distancesubstantially equal to the distance from the tongue to a longitudinalaxis of the lumen.

Yet another object of the present invention is to provide a method ofarthroscopic anterior cruciate ligament reconstruction of the kneeincluding forming a closed or open end femoral bone tunnel in the femuralong a guide wire precisely positioned by a femoral guide insertedthrough a tibial bone tunnel from an anterolateral or anteromedialportal such that a longitudinal axis of the femoral bone tunnel isdisposed 6–7 millimeters anterior to a posterior edge or “over-the-topridge” of a notch on the femoral condyle.

Some of the advantages of the present invention are that accurate,isometric positioning of tibial and femoral bone tunnels in arthroscopiccruciate ligament reconstruction is enhanced, the time required toperform arthroscopic anterior cruciate ligament reconstruction isreduced, error in forming bone tunnels in arthroscopic cruciate ligamentreconstruction is minimized, femoral bone tunnels can readily be locatedhigh in a notch formed in the femur, the use of blind, or closed-end,femoral bone tunnels as well as open-end femoral bone tunnels inarthroscopic anterior cruciate ligament reconstruction is permitted, thecreation of a trough and not a tunnel when forming femoral bone tunnelsis avoided, a cortical margin that is neither too wide nor too narrow isinsured, tunnel placement can be verified prior to tunnel formation, thefemoral isometric point can be accurately identified, the need forsurgeons to estimate the position of drills and reamers when formingfemoral bone tunnels along guide wires is eliminated, anteromedial andanterolateral portals can be used for inserting guide wires inarthroscopic anterior cruciate ligament reconstruction, the size ofportals used in arthroscopic cruciate ligament reconstruction can beminimized, the femoral guide according to the present invention isstreamlined in structure, right and left knee compatible and can besterilized for repeated use, the tip of a guide wire positioned by thefemoral guide on a bone surface can be viewed endoscopically, afootprint can be created on a bone surface as guided by a guide wirepositioned by the femoral guide and examined prior to forming a bonetunnel allowing adjustments to be made if necessary, the femoral guideis designed to be accommodated in portals of very small size and theconfiguration of the femoral guide facilitates manipulation andmaneuverability at the knee joint as well as arthroscopic visualizationof the knee.

Accordingly, these and other objects and advantages are obtained withthe present invention as characterized in a femoral guide including anelongate body having a distal end, a proximal end and a longitudinallumen for receiving a guide wire and a handle mounting the proximal endof the body. The body includes a cylindrical member and a tip extendingangularly, distally from the cylindrical member. The lumen extendsthrough the cylindrical member from the proximal end toward the distalend, the lumen terminating distally at an opening on an arcuate surfaceof the tip, the opening being disposed proximally of the distal end. Thelumen has a diameter sized to closely receive the outer diameter of aguide wire inserted through the femoral guide such that a longitudinalaxis of the guide wire is substantially aligned with a longitudinal axisof the lumen, and the opening of the lumen allows the guide wire toprotrude distally from the body to contact a bone surface. The arcuatesurface of the tip terminates distally at an end wall at the distal end,and a tongue protrudes distally from the end wall and, therefore, thedistal end, of the body. The tongue has a surface for engaging areference edge on a surface of the bone, and the surface of the tongueis disposed a predetermined distance from the longitudinal axis of thelumen such that a guide wire inserted through the lumen will bepositioned in contact with the bone surface a distance from the edgethat is substantially equal to the predetermined distance. A stylusprotrudes from the end wall in the same direction as the tongue allowingthe stylus to be driven through the bone surface and into the bone withthe bone surface abutting the end wall and the tongue engaging thereference edge. The guide wire can be driven into the bone along thelumen, and the femoral guide can be removed from the guide wire allowingan instrument, such as a cannulated drill or reamer, to be mounted onthe guide wire with the guide wire extending through the cannulation todrill a tunnel in the bone substantially concentrically or coaxiallyalong the guide wire such that a longitudinal axis of the tunnel isdisposed from the reference edge substantially the predetermineddistance. A method of forming bone tunnels endoscopically, orarthroscopically, in joints of the body such as the knee includes thesteps of inserting the femoral guide at the joint through a portal ofminimal size, positioning a tongue of the femoral guide in engagementwith a reference edge on a surface of a bone of the joint, inserting aguide wire through a lumen of the femoral guide and contacting the bonesurface with the guide wire at a location spaced from the edge adistance substantially equal to the distance from the tongue to alongitudinal axis of the lumen, driving the guide wire into the bonethrough the lumen and forming a bone tunnel in the bone substantiallyconcentrically or coaxially along the guide wire.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a side view of a femoral guide according to the presentinvention.

FIG. 2 is a front view of the femoral guide of FIG. 1.

FIG. 3 is an enlarged, broken side view, partly in section, of thefemoral guide of FIG. 1.

FIG. 4 is a broken top view of the femoral guide of FIG. 1.

FIG. 5 is a perspective view of a knee showing the femoral guide of FIG.1 inserting a guide wire in the femur from an anteromedial portal.

DESCRIPTION OF THE PREFERRED EMBODIMENTS

A femoral guide according to the present invention is shown at 10 inFIG. 1 and includes a body or probe 12 having a distal end 14, aproximal end 16 and a longitudinal axis and a handle 18 mounting theproximal end 16 of the body 12. The body 12 is preferably made ofstainless steel and includes an elongate, cylindrical member or tube 20terminating proximally at proximal end 16 and a tip 22 distally joinedto the cylindrical member 20, the cylindrical member 20 having alongitudinal axis coaxially aligned with the longitudinal axis of thebody 12. The tip 22 extends angularly, distally from the cylindricalmember 20 and includes an arcuate surface 24 extending distally from awall of the cylindrical member 20 with an inward curvature and anopposed arcuate surface 26 extending distally wit an inward curvaturefrom a wall of the cylindrical member 20. The arcuate surface 24terminates distally at an end wall 28 at the distal end 14, the end wall28 having a planar surface disposed in a plane transverse andperpendicular to the longitudinal axis of the body 12 as shown in FIG.3. A tongue 30 protrudes or extends distally from the end wall 28 and,therefore, the distal end 14, in a direction parallel with thelongitudinal axis of the body 12, the tongue 30 terminating distally atan arcuate segment 32 as shown in FIG. 4. The tongue 30 is of generallyuniform width and thickness and has a planar surface 34 extendingperpendicularly from the end wall 28 to the arcuate segment 32 parallelwith and offset from the longitudinal axis of the body and an opposedplanar surface 36 joined to arcuate surface 26 and extending from thearcuate surface 26 to the arcuate segment 32 parallel with the uppersurface 34. A pair of opposing, parallel side walls 38 having planarsurfaces laterally, equidistantly disposed with the longitudinal axis ofthe body 12 join the arcuate surfaces 24 and 26, the end wall 28 and thetongue 30 with the side walls 38 merging wit the cylindrical wall of thebody 12 as shown in FIGS. 3 and 4. A longitudinal passage or lumen 40extends through the body 12, the lumen 40 having a diameter sized toclosely receive the outer diameter of a guide wire or pin 41 as shown inFIG. 3 and as will be explained in greater detail below, and alongitudinal axis coaxially aligned with the longitudinal axis of thebody 12 such that the longitudinal axis of the lumen is spaced from theupper surface 34 of the tongue 30 by a predetermined distance. The lumen40 includes a first diameter section 42 in cylindrical member 20extending from the proximal end 16 in a distal direction and a second,relatively larger diameter section 44 coaxially aligned with the firstdiameter section 42 and distally joined to the first diameter section 42within the cylindrical member 20 at an internal, annular shoulder 46,the second diameter section 44 extending distally from the shoulder 46through the tip 22 to an opening 48 on the arcuate surface 24 that isgenerally oval or elliptical in configuration when viewed from above asshown in FIG. 4 with the opening 48 being disposed proximally of the endwall 28 and, therefore, the distal end 14. A stylus 50 having a sharppoint or lip 52 protrudes distally from the end wall 28 in the samedirection as the tongue 30, the stylus 50 having a generally conicalconfiguration with the point 52 at the apex of the conical stylus and anaxis of the stylus trough the apex being parallel with the upper surface34 of the tongue 30 such that the stylus can be driven into bone withthe end wall 28 abutting a surface of the bone and an edge of the bonesurface engaged by the upper surface 34 of the tongue 30 as will beexplained further below.

The body 12 can be of integral, unitary construction, or the body 12 canbe formed of multiple pieces joined at junctions, such as shown byjunction 54 in FIG. 4, by techniques such as welding. Where the body isformed of multiple parts or pieces, it is preferred that the junction 54be disposed at least 0,250 inches proximally of the shoulder 46. The tip22 can be formed as a single piece of unitary, integral construction orthe tip 22 can be formed of multiple pieces joined by techniques such aswelding allowing the stylus 50 and the tongue 30 to be formed separatelyfrom the body 12. The body 12 can have various configurations andarrangements of parts providing a lumen sized to closely receive theouter diameter of a guide wire or pin and a tongue protruding distallyfrom the body and having a surface for engaging an edge of a bonesurface to position a longitudinal axis of a guide wire received in thelumen on the bone surface a distance from the edge that is substantiallyequal to the distance from the surface of the tongue to the longitudinalaxis of the lumen. Accordingly, it will be appreciated that the lumen 40need not be coaxially aligned with the body 12, and that thelongitudinal axis of the lumen 40 can be offset from the longitudinalaxis of the body 12. Depending on the configuration of the bone surfaceand the edge of the bone surface to be engaged by the tongue, the uppersurface of the tongue need not be parallel to the longitudinal axis ofthe lumen and the end wall need not be perpendicular thereto.Accordingly, it will be appreciated that the tongue and end wall canhave various configurations and that the tongue can be angled andnon-parallel to the end wall and the longitudinal axis of the lumen. Thestylus 50 can have various configurations and can be assembled on thebody 12 at various locations to allow the stylus to be driven into bonewith an edge of a bone surface engaged by the tongue 30 to secure andstabilize the femoral guide prior to inserting a guide wire through thelumen and when driving the guide wire into bone. According to apreferred embodiment of the femoral guide 10, the diameter of the firstdiameter section 42 is substantially 0.099 inches to receive a guidewire or pin having an outer diameter of 0.0985 inches, the distance fromthe upper surface 34 to the longitudinal axis of the lumen 40 issubstantially 0.276 inches such that a bone tunnel formed substantiallyconcentrically or coaxially along a guide wire positioned through thelumen of the femoral guide will have a longitudinal axis disposed 6–7millimeters from the edge of the to bone surface engaged by the tongue30. The length of tongue 30 from end wall 28 to arcuate segment 32 issubstantially 0.375 inches, the length of stylus 50 from end wall 28 topoint 52 is substantially 0.155 inches, the radius of curvature forarcuate surface 24 measured from a point 3.00 inches from the lowersurface 36 and 0.23 inches proximally from arcuate segment 32 looking atFIG. 3 is substantially 2.78 inches, the radius of curvature for arcuatesegment 26 measured from a point 2.40 inches from the lower surface 36and 1.56 inches proximally from the arcuate segment 32 looking at FIG. 3is substantially 2.65 inches, the outer diameter of cylindrical member20 is substantially 0.190 inches, the distance between the side walls 38is substantially 0.150 inches and the overall length of the body 12 fromarcuate segment 32 to the proximal end 16 is substantially 6.00 inches.It will be appreciated that the dimensions of the femoral guide candepart from those described here as illustrative and that the femoralguide 10 can have various dimensions and configurations allowing thefemoral guide to be inserted through portals of minimal size and to bemanipulated within close confines of joints in the body.

The handle 18 is preferably made of stainless steel and includes amounting section 54 having a longitudinal, cylindrical passage 55therein with a diameter sized to closely receive the outer diameter ofthe cylindrical member 20 of body 12 and a gripping section 58 extendingangularly outwardly from the mounting section 54. The mounting section54 has a pair of opposing side walls 60 defining a width that tapers inthe direction of the cylindrical passage 55 as shown in FIG. 2 and apair of curved forward and rearward walls 62 and 64, respectively,joining the side walls 60 as shown in FIG. 1. As shown in FIG 1, theforward and rearward walls 62 and 64 curve toward each other such thatthe length of the handle tapers from near the cylindrical passage 55 tothe gripping section 58. The gripping section 58 includes a pair of sidewalls 66 joined to the side wall 60 and terminating at a radial wall 68as shown in FIG. 2, and forward and rearward walls 70 and 72,respectively, joining the side walls 66 as shown in FIG. 1. The forwardand rearward walls 70 and 72 are joined, respectively, to the forwardand rearward walls 62 and 64 of the mounting section 54. Ridges 74 areprovided on the rearward wall 72 of the gripping section 58, the ridges74 extending transverse to the side walls 66 to facilitate grasping ofthe handle 18 during use. Indicia can be provided on the side walls 60of the mounting section or at any other suitable location on the handle18 to identify the distance from the upper surface 34 of tongue 30 tothe longitudinal axis of the lumen 40. The cylindrical member 20 of thebody 12 is concentrically mounted in the passage 55 of the handle 18with the proximal end 16 of the body 12 extending proximally of themounting section 54 a short distance and, preferably, 0.375 inches, asshown in FIG. 1, and the gripping section 58 is disposed diametricallyopposite the tongue 30. The body 12 can be secured to handle 18 bytechniques such as welding allowing the femoral guide 10 to besterilized for repeated use utilizing known sterilization procedures.With the body 12 assembled with the handle 18, the gripping section 58extends angularly, distally in a direction outwardly from thelongitudinal axis of the body 12 such that the handle section 58 isdisposed at an acute angle with the longitudinal axis of the body 12 forengagement in an inverted position. It will be appreciated that thehandle 18 can have various structural configurations to mount the body12 and provide a ripping section permitting the femoral guide 10 to begrasped and held conveniently, from externally of the body, and toposition the tip 22 in the body via a portal of minimal size.

According to a method of operation for the guide 10 in precisely formingbone tunnels in a bone of a joint endoscopically, the femoral guide 10is inserted at a joint in the body through a portal of minimal sizeformed in tissue adjacent the joint with the joint being visualizedendoscopically. With the handle 18 manually grasped and held in aninverted position externally of the body, the tip 22 is manipulated toposition the upper surface 34 of the tongue 30 against an edge of a bonesurface that is to have a tunnel entry thereon. With the edge of thebone surface abutting the upper surface 34 of the tongue 30, thelongitudinal axis of the lumen 40 will be spaced from the edge adistance that is equal to the distance from the upper surface 34 to thelongitudinal axis of the lumen 40. The guide 10 is then driven towardthe bone surface such that the sharp point 52 of the stylus 50 entersthe bone surface and secures and stabilizes the femoral guide. A guidewire or pin, such as guide wire 41 shown in FIG. 3, is inserted in thelumen 40 from the proximal end 16 of the guide 10 externally of thebody. The guide wire 41 will exit the lumen 40 through the opening 48and, by moving the guide wire 41 toward the bone surface, a tip of theguide wire 41 will contact the bone surface at a point that is spacedfrom the edge a distance substantially equal to the distance from theupper surface 34 to the longitudinal axis of the lumen 40. The curvatureof the arcuate surface 24 allows the tip of the guide wire 41 to be seenendoscopically. An end of the guide wire 41 protruding from the proximalend 16 is coupled, externally of the body, with a tool or instrument fordrilling the guide wire in bone, and the guide wire is drilled a desireddepth into the bone. The guide 10 is then removed from the guide wirethrough the portal and a tunneling instrument, such as a drill orreamer, having a central cannulation is mounted on the guide wire 41externally of the body with the guide wire extending through thecannulation. The tunneling instrument is inserted at the joint throughthe portal and, with the instrument guided by the guide wire 41, a bonetunnel is formed substantially concentrically or coaxially along theguide wire 41 in the bone to a desired depth such that a longitudinalaxis of the bone tunnel is located from the edge a distancesubstantially equal to the distance from the upper surface 34 to thelongitudinal axis of the lumen 40. Accordingly, the guide 10 accordingto the present invention allows bone tunnels to be formed in bone alongguide wires with entry points of the bone tunnels located on surfaces ofthe bone by positioning the guide wires with the guide at the centers ofthe tunnel entry points such that the tunnel entry points are preciselylocated on the bone surfaces in relation to reference points or edges onthe bone surfaces that can be engaged by the tongue of the guide.

The femoral guide 10 according to the present invention is useful invarious diverse types of surgical procedures involving the need toprecisely position and form bone tunnels in bone endoscopically and, inparticular, the femoral guide 10 is useful in ligament reconstruction injoints of the body and, especially, the knee. The femoral guide 10 canbe used in reconstructing various diverse types of ligaments and, whenused to reconstruct ligaments of the knee, the femoral guide 10 isparticularly useful in forming bone tunnels arthroscopically whenreconstructing the anterior cruciate ligament of the knee. According toa method of arthroscopic anterior cruciate ligament reconstruction ofthe knee, a portal of minimal size is formed in tissue adjacent the kneeto access the knee joint with the knee being visualized with anarthroscope. A diagnostic arthroscopy can be performed prior to anteriorcruciate ligament reconstruction without having to commit to an anteriorcruciate ligament reconstruction unless confirmed by the arthroscopicfindings. The portal should be placed anteromedial or anterolateral onthe knee and, preferably, the portal is placed medially on the knee as aportal placed too high can result in too steep an angle for the tibialbone tunnel while a portal placed too low can interfere with themeniscus. The portal should be placed just superior to the medialmeniscus and must not penetrate any portion of the patellar tendon.Instruments are inserted through the portal to perform any necessaryprocedures such as meniscectomy, minuscal repair, removal of loosebodies, and debridemnent of anterior cruciate ligament tears. Aninstrument is inserted through the portal to perform a notchplastyresulting in a notch 76, as shown in FIG. 5, on the femoral condyle, thenotch 76 being approximately 2 centimeters in width and adequatelyposterior to include the extreme posterolateral femoral cortex andhaving a surface 77 terminating at a posterior edge or “over-the-top”ridge 78. Where an autogenous graft ligament is utilized a graft havingbone blocks at its ends is harvested from the patellar tendon throughvertical incisions, i.e., an anteromedial incision or portal beginning 1centimeter medial to the tibial tubercle and 2 centimeters distally tothe joint line and being 2.5 centimeters in length and a patellarincision 2.5 centimeters in length and beginning at the distal pole ofthe patella and extending proximal over the midline of the patella. Aguide wire or pin is placed at the anatomic center of the tibial tunnelentry on the tibia via an anterolateral portal or the anteromedialportal 80 previously used to harvest the graft. An instrument such as adrill or reamer having a cannulation is mounted on the guide wire withthe guide wire extending through the cannulation, and a tunnel 82 isdrilled in the tibia substantially concentrically or coaxially along theguide wire at a site anatomically equivalent to the anterior cruciateligament. The drill or reamer and the guide wire are removed from thetibia and, with the knee at an angle of 30.degree. to 45.degree., thefemoral guide 10 is introduced through the tibial bone tunnel 82 fromthe anteromedial or anterolateral portal 807 and the femoral guide 10 isadvanced across the knee joint with the handle 18 held externally of thebody. The tongue 30 of the femoral guide 10 is positioned against theposterior edge or ridge 78 and, once positioned, the femoral guide 10 ismoved toward the surface 77 to drive the stylus 50 through the surface77 and into the femur thusly securing or stabilizing the femoral guide10. A guide wire 41 is inserted through the lumen of the femoral guidefrom externally of the body such that a tip of the guide wire protrudingthrough the opening 48 contacts the surface 77 to establish alongitudinal axis or center for an entry point of a tunnel to be formedin the femur along the guide wire 41, the arcuate surface 24 allowingthe tip of the guide wire 41 to be seen arthroscopically. A desiredposition for the femoral bone tunnel is high in the notch 76 with alongitudinal axis or center of the femoral bone tunnel locatedapproximately 6–7 millimeters anterior to the edge or ridge 78, and thedistance from the upper surface 34 of the tongue 30 to the longitudinalaxis of the lumen 40 results in the guide wire 41 being placed at thedesired position on the surface 77. An end of the guide wire 41protruding from the proximal end 16 of the femoral guide 10 is coupledwith an instrument for drilling the guide wire 41 in bone, and the guidewire 41 is drilled into the femur as shown in FIG 5. The guide wire isdrilled into the femur a depth of approximately 3–4 centimeters for ablind, or closed end, femoral bone tunnel and, for an open end femoralbone tunnel, the guide wire 41 is drilled into the femur until it exitsthe lateral femoral cortex but not through the skin. The femoral guide10 is backed out of the femur and removed from the knee through theportal SO, and an instrument for forming a bone tunnel, such as a drillor reamer, having a cannulation therein is mounted on the guide wire 41with the guide wire extending through the cannulation. The drill orreamer is inserted through the portal 80 along the guide wire, and afootprint of the drill or reamer is created on the surface 77 andexamined arthroscopically to insure accurate positioning of the femoralbone tunnel entry point. The width of the posterior cortex remainingshould be approximately 1–2 millimeters, the posterolateral femoralcortex must be adequately identified and the femoral bone tunnel shouldbe as far posterior as possible while still allowing a tunnel and not atrough. If the cortical margin is too wide or too narrow, the guide wire41 may be reinserted and another footprint made and examined untilaccurate placement of the bone tunnel is confirmed. Once the entry pointfor the femoral bone tunnel has been properly placed, the femoral bonetunnel is drilled along the guide wire and, for a blind tunnel, thetunnel is drilled slightly deeper than the length of the bone blockintended for fixation in the femoral bone tunnel and, for an opentunnel, the tunnel is drilled through the lateral femoral cortex. Thedrill or reamer and the guide wire 41 are removed through the portal 80,and the autogenous ligament or a prosthetic ligament is inserted throughthe tibial bone tunnel and across the knee joint with a bone blockdisposed in each of the bone tunnels. Interference bone fixation screwsare then inserted in the tibial and femoral bone tunnels laterallybetween the bone blocks and walls of the bone tunnels indirectionsparallel with longitudinal axes of the bone tunnels to fixate theligament.

Accordingly, the femoral guide and methods of forming bone tunnelsendoscopically according to the present invention allow bone tunnels tobe precisely formed endoscopically in bone along guide wires bypositioning the guide wires such that longitudinal axes of the bonetunnels formed substantially concentrically or coaxially along the guidewires are spaced from reference edges on the bone a predetermineddistance. The femoral guide of the present invention allows femoral bonetunnels to be precisely positioned in arthroscopic cruciate ligamentreconstruction at sites anatomically equivalent to the cruciate ligamentto insure accurate graft prosthetic ligament placement and isometricity.The femoral guide permits the use of small size portals in arthroscopiccruciate ligament reconstruction and is designed to facilitatemanipulation and maneuverability at the knee joint. The femoral guidefacilitates arthroscopic viewing of the tip of the guide wire on thefemoral condyle and examination of the footprint created prior toforming the femoral bone tunnel. The femoral guide and the methods offorming bone tunnels according to the present invention allow guidewires to be inserted at he knee from anterolateral and anteromedialportals and reduce the number of portals required in arthroscopiccruciate ligament reconstruction of the knee. By precisely positioning aguide wire a predetermined distance from an edge on a bone surface, thefemoral guide and methods of forming bone tunnels according to thepresent invention avoid errors in placing bone tunnels and eliminate theneed for surgeons to estimate where to put instruments, such as drillsor reamers, when forming bone tunnels. The tongue of the femoral guideaccording to the present invention allows an edge, a ridge or some otherstructure of bone to be used as a reference in forming bone tunnels suchthat longitudinal axes of bone tunnels formed along guide wirespositioned via the femoral guide will be located a predetermineddistance from the reference. The stylus of the femoral guide enhancesaccuracy and precision in forming bone tunnels by securing orstabilizing the femoral guide relative to the bone prior to drilling theguide wire.

Inasmuch as the present invention is subject to many variations,modifications and changes in detail, it is intended that all subjectmatter discussed above or shown in the accompanying drawings beinterpreted as illustrative only and not be taken in a limiting sense.

1. A guide for positioning a wire on a bone having a bone surface withan edge to allow a tunnel to be formed in the bone along the guide wireincluding: an elongated body having a distal end and a proximal end,said body including an sloping surface extending towards an end wall atsaid distal end, said end wall being disposed in a plane; a lumen insaid body for receiving a guide wire and having a longitudinal axissubstantially perpendicular to the plane in which said end wall isdisposed, said lumen extending from said proximal end to an openingformed on said sloping surface for allowing the guide wire to protrudefrom said body to contact the bone surface; and a tongue on said bodyhaving a surface spaced from said longitudinal axis and protrudingdistally from said end wall beyond said opening for engaging the edge ofthe bone surface whereby a guide wire protruding from said body contactsthe bone surface at a location spaced from the edge a distancesubstantially equal to the distance that said surface of said tongue isspaced from said longitudinal axis of said lumen.
 2. The guide accordingto claim 1, wherein the elongated body includes a cylindrical member. 3.The guide according to claim 1, wherein said sloping surface forms anacute angle with the longitudinal axis.
 4. The guide according to claim1, wherein said sloping surface forms an angle with said plane of saidend wall.
 5. The guide according to claim 1, wherein said tongue issubstantially parallel to the longitudinal axis.
 6. A guide forpositioning a wire on a bone having a bone surface with an edge to allowa tunnel to be formed in the bone along the guide wire including: anelongated body having a proximal end and a distal end; a lumen formed inthe elongated body for receiving a guide wire, the lumen having alongitudinal axis; an angled member having a first end connected to theelongated body at the proximal end, the lumen extending through theangled member terminating at a side surface, the side surface extendingtoward an end wall substantially perpendicular to the longitudinal axisof the lumen, the side surface forming an angle with the longitudinalaxis of the lumen, such that prior to contacting the bone surface thewire visibly protrudes from the side surface; and a tongue attached tothe angled member having a surface spaced from the longitudinal axis ofthe lumen and protruding distally from the end wall whereby the guidewire protruding from the angled member contacts the bone surface at alocation spaced from the edge a distance substantially equal to thedistance that the surface of the tongue is spaced from the longitudinalaxis of the lumen.
 7. A guide for positioning a wire on a bone having abone surface with an edge to allow a tunnel to be formed in the bonealong the guide wire including: an elongated body having a distal endand a proximal end, said body including a surface having a bend, thesurface extending toward an end wall at said distal end, said end wallbeing disposed in a plane; a lumen in said body for receiving a guidewire and having a longitudinal axis perpendicular to the plane in whichsaid end wall is disposed, said lumen extending from said proximal endto an opening formed on the surface having a bend for allowing the guidewire to protrude from said body to contact the bone surface; and atongue on said body having a surface spaced from said longitudinal axisand protruding distally from said end wall beyond said opening forengaging the edge of the bone surface whereby a guide wire protrudingfrom said body contacts the bone surface at a location spaced from theedge a distance substantially equal to the distance that said surface ofsaid tongue is spaced from said longitudinal axis of said lumen.
 8. Theguide according to claim 7 wherein the elongated body includes acylindrical member.
 9. A method of precisely forming a bone tunnel in asecond bone having a bone surface with an edge including the steps of:providing a guide having an elongated body with a lumen therethrough anda tongue spaced a fixed predetermined distance from the longitudinalaxis of said lumen; inserting the guide and the tongue through apreviously formed tunnel in a first bone, and positioning the tongue ofthe guide in engagement with the edge; inserting a guide wire throughthe lumen of the guide to contact the bone surface at a location spacedfrom the edge a distance substantially equal to the fixed predetermineddistance from the tongue to the longitudinal axis of the lumen; drivingthe guide wire into the second bone through the lumen; removing theguide from the guide wire; and mounting an instrument on the guide wireand forming a bone tunnel in the second bone with the instrumentsubstantially concentrically along the guide wire.
 10. A methodaccording to claim 9, wherein the elongated body has an angled surfacehaving a curve wherein the lumen terminates on the angled surfacewhereby prior to contacting the second bone the guide wire is visible.11. A method of precisely forming a bone tunnel as recited in claim 9wherein said step of inserting a guide wire includes inserting a guidewire having a longitudinal axis in the lumen with the longitudinal axisof the guide wire substantially coaxially aligned with the longitudinalaxis of the lumen.
 12. A method of precisely forming a bone tunnel asrecited in claim 9 wherein said lumen has a diameter and said step ofinserting a guide wire includes inserting a guide wire having an outerdiameter to be closely received by the diameter of the lumen.
 13. Amethod of precisely forming a bone tunnel as recited in claim 9 furtherincluding, prior to said step of inserting a guide wire, the step ofsecuring the guide to the bone.
 14. A method of precisely forming a bonetunnel as recited in claim 13 wherein said step of securing includes thestep of driving a stylus on the guide into the bone.
 15. A method ofprecisely forming a bone tunnel as recited in claim 9, wherein the firstbone is a tibia and the second bone is a femur.
 16. A method ofprecisely forming a femoral bone tunnel in arthroscopic cruciateligament reconstruction of the knee including the steps of forming aportal of minimum size in tissue adjacent the knee; visualizing the kneewith an arthroscope; inserting an instrument through the portal andperforming a notchplasty in the femur creating a surface on the femoralcondyle terminating at a posterior edge; inserting an instrument througha portal and forming a tunnel in the tibia at a site anatomicallyequivalent to the cruciate ligament; positioning a femoral guide throughthe portal and engaging the posterior edge of the surface on the femoralcondyle with a tongue of the femoral guide; inserting a guide wirehaving a longitudinal axis through a lumen of the femoral guide fromexternally of the knee with the longitudinal axis of the guide wiresubstantially aligned with a longitudinal axis of the lumen; contactingthe surface of the femoral condyle with the guide wire through the lumento position the guide wire on the surface of the femoral condyle adistance from the posterior edge that is substantially equal to thedistance from the tongue to the longitudinal axis of the lumen; drivingthe guide wire into the femur along the lumen; removing the femoralguide through the portal; and inserting an instrument along the guidewire from externally of the knee through the portal and forming a bonetunnel in the femur substantially concentrically along the guide wire.17. A method of precisely forming a femoral bone tunnel as recited inclaim 16 wherein said step of forming a portal includes forming a portalanteromedial or anterolateral in the knee.
 18. A method of preciselyforming a femoral bone tunnel as recited in claim 16 wherein thedistance from the tongue to the longitudinal axis of the lumen isapproximately 6–7 millimeters and said step of inserting a guide wireincludes the step of contacting the surface of the femoral condyle withthe guide wire approximately 6–7 millimeters anterior of the posterioredge.
 19. A method of precisely forming a femoral bone tunnel as recitedin claim 16 wherein said step of driving the guide wire into the femur adepth of approximately 3–4 centimeters.
 20. A method of preciselyforming a femoral bone tunnel as recited in claim 16 wherein said stepof forming the femoral bone tunnel includes forming the femoral bonetunnel in the femur to a depth slightly greater than the length of abone block to be disposed in the femoral bone tunnel.
 21. A method ofprecisely forming a femoral bone tunnel as recited in claim 16 whereinsaid step of driving the guide wire includes driving the guide wire intothe femur until the guide wire exits through the lateral femoral cortexof the femur.
 22. A method of precisely forming a femoral bone tunnel asrecited in claim 16 wherein said step of forming the femoral bone tunnelincludes forming the femoral bone tunnel in the femur to extend throughthe lateral femoral cortex of the femur.
 23. A method of preciselyforming a femoral bone tunnel as recited in claim 16 further including,prior to said step of forming the femoral bone tunnel, the steps ofcreating a footprint with the instrument on the surface of the femoralcondyle and examining the footprint for accurate positioning of thefemoral bone tunnel.
 24. A method of precisely forming a femoral bonetunnel as recited in claim 16 further including, prior to said step ofpositioning a femoral guide, the step of positioning the knee at anangle of 30–45°.
 25. A method of precisely forming a bone tunnelendoscopically in a joint of the body including the steps of: forming aportal of minimal size in tissue adjacent to the joint; visualizing thejoint endoscopically; inserting a guide at the joint through the portal;positioning a tongue of the guide against the edge of a surface of abone of the joint; inserting a guide wire having a longitudinal axisthrough a lumen of the guide to contact the bone surface, the lumenhaving a longitudinal axis spaced from the tongue a predetermineddistance to position the guide wire on the bone surface a distance fromthe edge that is substantially equal to the predetermined distance;driving the guide wire into the bone along the lumen; removing the guidethrough the portal; and inserting an instrument along the guide wirethrough the portal and forming a bone tunnel in the bone with theinstrument along the guide wire.
 26. A method of precisely forming abone tunnel as recited in claim 25 wherein said step of driving includesdrilling the guide wire into the bone through the lumen.
 27. A method ofprecisely forming a bone tunnel as recited in claim 26 wherein said stepof forming a bone tunnel includes the step of reaming a bone tunnel inthe bone substantially concentrically along the guide wire.
 28. A methodof precisely forming a bone tunnel as recited in claim 27 furtherincluding, prior to said step of inserting the guide wire, the step ofsecuring the guide to the femur with the tongue against the edge.